MMD-ASMG-01-05
NOMINATION/ APPLICATION FORM FOR SENIOR MEMBER GRADE
2” x 2” white background Photo
1. Full Name ___________________________________________________________________ First Name M.I. Family Name 2. Home Address ________________________________________________________________ 3. Present Position : _____________________________________________________________ Company/ Affiliation : __________________________________________________________ Address : ___________________________________________________________________ Telephone No. : ______________________________________________________________ 4. Education : BACHELOR School : Degree : Year :
MASTER
DOCTORATE
____________________ ____________________ ________________________ ____________________ ____________________ ________________________ ____________________ ____________________ ________________________
5. Professional License/ s ( (
) )
Professional EE No. Registered EE No.
____________________ Year ____________________ ____________________ Year ____________________
6. Life Member Year Accepted : _______________________ 7. Specific, significant and substantial achievements in the field of electrical engineering, giving relevant details, extent of responsibility and involvement, subject to verification. (Please accomplish attached form.)
Signature :
____________________________________
Date : ___________________
(Nomination/ Application Form was revised during the Selection and Awards Committee Meeting on July 2, 2005 and was approved by the Board of Governors during the Regular Board Meeting on July 22, 2005.)